1. Peripheral Arterial Disease
Dr. Rehab F.M.Gwada

2. Objectives of the Lecture
The student at the end of this lecture will be able
To define Peripheral Arterial Disease(PAD)& associated risk factors.
To describe its causes &pathogenesis.
To explain the clinical pictures associated with PAD
to diagnose PAD& outline appropriate treatment goals?
To describe the strategies of Treatment in patient with PAD ?

3. Content of Lecture What is Peripheral Arterial Disease?
What are the risk factors for PAD?
Peripheral Vascular Disease Causes& Pathogenesis
Symptoms of PAD
How do we diagnose PAD?
Goals of treating patients with PAD
the strategies of Treatment in patients with PAD

4. Arteries Large elastic arteries have walls consisting of: Tunica Media
Tunica Intima
Consist of endothelium, subendothelium& elastic tissue
Function: to prevent intravascular clotting
Tunica Media
Consist of: smooth muscle &elastic fiber
Function: to propel the blood
Tunica Adventitia
Consist of connective tissue and small blood vessels
Function: to prevent undue expansion of artery

6. Peripheral Vascular Disease
Peripheral Vascular Disease (PVD) refers to diseases of blood vessels outside the heart and brain. It's often a narrowing of vessels that carry blood to the legs, arms, stomach or kidneys. There are two types of these circulation disorders
Functional peripheral vascular diseases don't have an organic cause. They don't involve defects in blood vessels' structure. They're usually short-term effects related to "spasm" that may come and go. Raynaud's disease is an example. It can be triggered by cold temperatures, emotional stress, working with vibrating machinery or smoking.
Organic peripheral vascular diseases are caused by structural changes in the blood vessels, such as inflammation and tissue damage. Peripheral artery disease is an example. It's caused by fatty buildups in arteries that block normal blood flow.
Peripheral Vascular Disease
PVD definition is from the American Heart Association

7. What is Peripheral Arterial Disease?
Peripheral arterial disease (PAD), commonly referred to as peripheral artery occlusive disease (PAOD), refers to the obstruction of large arteries not within the heart vasculature, or brain.
PVD can result from atherosclerosis, inflammatory processes leading to stenosis, an embolism, or thrombus formation. It causes either acute or chronic ischemia (lack of blood supply).
Often PAD is a term used to refer to atherosclerotic blockages found in the lower extremity.

8. Signs &Symptoms
About 20% of patients with mild PAD may be asymptomatic; other symptoms include:
Claudication - pain, weakness, numbness, or cramping in muscles due to decreased blood flow.
Claudication
walking induced pain in one or both legs [primarily affecting calves] does not go away with continued walking , relieved by rest
Present in 15-40% of PAD
Associated with diminished ability to perform ADL

9. Signs &Symptoms Noticeable change in color (blueness or paleness).
Paleness of the leg or foot when elevated
Blue/red discoloration of the foot when hanging down
Absence of pulses in the foot.
coolness.
Diminished hair and nail growth on affected limb and digits.
Sores, wounds, or ulcers that heal slowly or not at all.
gangrene of the digits.

10. How do patients with PAD present?

11. What are the risk factors for PAD?
Non-Modifiable Risk Factors:
Male gender
Advanced age
Family history
Modifiable Risk Factors:
Major
Smoking
Hypertension
Diabetes
Hyperlipidemia
Minor
Homocystenemia
Obesity
Hypercoaguable state
Physical inactivity
Homocysteine: An amino acid that is produced by the human body, usually as a byproduct of consuming meat. Homocysteine is normally converted into other amino acids. An abnormal accumulation of homocysteine, which can be measured in the blood, can be a marker for the development of heart disease. Elevated levels of homocysteine in the blood appear to increase the risk of heart attack, stroke, peripheral vascular disease, and venous thrombo'embolism (blood clots in the veins). Homocysteine is believed to damage blood vessels in several ways. It injures the cells that line arteries and stimulates the growth of smooth muscle cells. Homocysteine can also disrupt normal blood clotting mechanisms. Elevated levels of homocysteine also appear to increase the risk of Alzheimer's disease. The ways to lower homocysteine are to eat less meat and take supplements of the B vitamins folic acid (folate), B6, and B12 that are needed by the enzymes that process homocysteine.

12. Peripheral Vascular Disease Causes
atherosclerosis.
Blood block: can block a blood vessel (thrombus/emboli).
Diabetes: Over the long term can damage blood vessels
Inflammation of the arteries: This condition is called arteritis and can cause narrowing or weakening of the arteries.

13. Peripheral Vascular Disease Causes
Infection: The inflammation and scarring caused by infection can block, narrow, or weaken blood vessels.
Structural defects can cause narrowing. Most of these cases are acquired at birth, and the cause remains unknown.
Injury Blood vessels can be injured in an accident

14. How do we diagnose PAD? History & symptomes Physical Examination
Capillary filling time:(2-3sec in worm day to 5sec in cold one)
Test for rubor
Non-invasive tests
ABI(Ankle Brachial Index) measurement
Segmental Pressures
Exercise Test
Doppler & duplex ultrasound,
MR angiography.
Invasive test (Contrast arteriography)

15. Test for rubor
Changes in skin color that occur with elevation and dependency for the limb are evaluated.
The legs are elevated & supported for 45 degree for one minute above the level of the heart while the patient is lying supine.
severe , wide Pallor of the skin will occur in the feet if arterial circulation is poor (within 25 sec. indicate severe ischema) .
The time necessary for blanching to develop is noted.
The legs are then placed in a dependent position, and the color of the feet is noted.

16. Test for rubor
Normally in dependency, a pinkish flush appears in the feet after several seconds(10sec).
Abnormally , in severe ischemia , the delay is 40 sec or more.
In occlusive arterial disease, a bright reddening or rubor of the distal legs and
feet occurs.
The rubor may take as long as 25 to 40  seconds to appear.
Dependent rubor. Note the reddish appearance of the left leg and foot on dependency compared to the normal color of the patient’s right foot and leg

17. Ankle Brachial Index
ABI= Ankle SBP/ Arm SBP

18. the severity of the PAD Ankle Brachial Index
ABI value
Indicates
<0.9
Abnormal
Mild PAD
Moderate PAD
<0.5
Severe PAD
<0.25
Very Severe PAD

19. PAD Diagnostic Test: Segmental Pressures
arteries of your leg. Similar to the ABI plus 2 or 3 additional blood pressure cuffs. These additional cuffs are placed just below the knee and one large cuff or two narrow cuffs are placed above the knee and at the upper thigh. These cuffs are then inflated above your normal systolic blood pressure, and then slowly deflated.
Using the Doppler instrument, a significant drop in pressure between two adjacent cuffs indicates a narrowing of the artery or blockage along the arteries in this portion of your leg. This allows the physician to identify more precisely the location of such blockages in the arteries of your leg .

20. Goals of treating patients with PAD
Relief symptoms
Limb salvage
Improve quality of life
Prolong survival

21. Strategies of Treatment for patients with PAD
Risk Factors Modification
Improve Lower Limb Circulation

22. Treatment of patients with PAD
Risk Factors Modification
Smoking Cessation
Hypertension control
Diabetes control
Regular exercise
Diet and weight control
Lipid control

23. Treatment of patients with PAD
Improve Lower Limb Circulation
Conservative (Exercise Program):
-Graded ambulation or bicycling program
- Burger-Allen Exercise
Antiplatelet( reduce risks of MI , ischemic stroke and death from vascular causes).
Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Plaque excision
- Surgical Bypass
- Rarely, sympathectomy is used amputation is often a last resort to stop infected ( In gangrene).

24. Angioplasty

25. Graded ambulation or bicycling program
The patient should be encouraged to walk or bicycling far as possible, without causing intermittent claudicationas
carried out 3 to 5 days per week
mild warm-up activities before initiating ex. include stretching calf ms , isometric pumping ex. For ankle & toes

26. Graded ambulation or bicycling program
Precautions:
avoid exercising outside during very cold weather
wear shoes that fit properly and will not cause skin irritations, blisters, or sores
Patient with a history of cardiac disorders , must be monitored closely

27. Graded ambulation or bicycling program
Contraindications: :
leg pain increased
over time
Patient with resting pain
ulcerations of the feet and wound or
fungal infections

28. Burger-Allen Exercise
Procedure:
A three-stage exercise procedure is carried out 3times /day.
First position(stage)
Patient lies supine with legs elevated and supported at a
45 to 60 degree angle.
Maintained position for 1 to 3 minutes, or until
blanching of the extremity occurs
actively dorsiflex and planterflex the feet

29. Burger-Allen Exercis

30. Burger-Allen Exercise
Second position(stage)
sits up and dangles his feet over
the edge of the bed..
actively dorsiflexes and planterflexes
his ankles for 3 minutes or until rubor in
the feet develops.

31. Burger-Allen Exercise
Third position(stage)
supine with his feet and legs covered with a blanket for warmth and rests for 5 minutes.
The entire three-stage procedure is repeated 3 to 6 times during each treatment session.

32. Burger-Allen Exercise
Termination:
Exercises and elevation of the limbs are discontinued if pain or cramping of the calf muscles occurs.
Contraindications:
-Recent acute thrombosis or embolus.
-Increased swelling in the lower extremities

33. Prognosis
Individuals with PAD have an elevated risk for cardiovascular events and the majority will eventually die of a cardiac ( 40%-60%) or cerebrovascular(10%-20%) etiology
prognosis is correlated with the severity of the PAD as measured by the Ankle brachial index (ABI).
In patients with intermittent claudication, the risk of death from coronary events is three to four times higher than matched controls without claudication.
Severity of PAD is closely associated with risk of MI , ischemic stroke , and death from vascular cause .

34. Discuss the Strategies of Treatment for patients with PAD?
Question
Discuss the Strategies of Treatment for patients with PAD?
Thank you